Spontaneous Coronary Artery Dissection (SCAD) is an underdiagnosed cause of acute coronary syndrome (ACS), accounting for up to 4% of all cases,1 that is often overlooked and misdiagnosed.2,3 SCAD predominantly affects young female patients (<50 years), accounting for nearly 8.7-25% of ACS in patients of this population.2,4 Several risk factors for SCAD have been proposed including female sex, emotional or physical stressors, and fibromuscular dysplasia.5,6 Clinical presentation is often ST-elevation myocardial infarction with multivessel involvement in up to 23% of cases, and diagnosis usually begins with coronary angiography and can be carefully aided with techniques such as intravascular ultrasound (IVUS) and optimized coherence tomography (OCT).2,5

Two pathophysiological mechanisms have been proposed for the formation of SCAD, which is defined as a non-traumatic non-iatrogenic separation of the coronary artery wall by an intramural hematoma.2 The “inside-out” theory proposes a disruption of the vasa vasorum leading to intramural hematoma formation, in contrast to the “outside-in” theory in which the intramural hematoma is caused by an endothelial rupture.7 Both theories have been supported by imaging with OCT,8 and the “outside-in” theory can explain the association with fibromuscular dysplasia which weakens arterial walls.2 Some studies propose that the higher prevalence of SCAD in female patients as well as its association with pregnancy and oral contraceptives may suggest a possible hormonal effect on vascular integrity. However, more research is needed to further clarify the role of hormones on this disease.9, 10, 11

Management of SCAD has been under debate. Although ACC/AHA guidelines for ACS generally advocate early interventional therapy, multiple studies have shown technical failure rates of up to 53% with percutaneous coronary intervention (PCI) as well as significant post-procedural complication rates such as worsening the existing hematoma.12, 13, 14 Despite recent attempts to optimize PCI approaches through techniques such as cutting balloon fenestration, multi-stent approach, and bioresorbable stents, data is generally limited to case reports and the current evidence points towards a more conservative approach for treating SCAD in most cases.

On the other hand, medical therapies for the management of SCAD have been proposed with varying levels of success, with outcomes being generally optimistic. There is scarce literature, mainly limited to observational studies and case reports, addressing the effectiveness of medical treatment options and their effectiveness for patients presenting with SCAD. Therefore, we sought to provide a comprehensive review that summarizes current treatment options and their associated outcomes on this category of patients